Form 0112 "Title VI - Complaint Form" - Michigan

What Is Form 0112?

This is a legal form that was released by the Michigan Department of Transportation - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the Michigan Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 0112 by clicking the link below or browse more documents and templates provided by the Michigan Department of Transportation.

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Download Form 0112 "Title VI - Complaint Form" - Michigan

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Clear Form
Michigan Department
TITLE VI - COMPLAINT FORM
Page 1 of 2
of Transportation
0112 (12/19)
Title VI of the Civil Rights Act of 1964 states that, "No person in the United States shall on the basis of race, color, or
national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to discrimination
in any program, service, or activity receiving federal financial assistance."
This form may be used to file a complaint with the Michigan Department of Transportation (MOOT) for alleged
violations of Title VI of the Civil Rights Act of 1964.
If you need assistance completing this form,
please
contact us by phone at (517) 373-0980 or via FAX (517) 335-8841 or TDD/TTY through the Michigan Relay
Center at (800) 649-3777.
Only the complainant or the complainant's designated representative should complete this form.
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE
WORK TELEPHONE
FAX
lndividual(s) discriminated against, if different from above (use additional page(s) if necessary):
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE NO.
WORK TELEPHONE NO.
FAX NO.
PLEASE EXPLAIN YOUR RELATIONSHIP TO THE INDIVIDUAL(S) INDICATED ABOVE
Name of Agency and department or program that discriminated:
AGENCY AND DEPARTMENT NAME
NAME OF INDIVIDUAL (If known)
STREET ADDRESS
I I
CITY
STATE
ZIP CODE
I
TELEPHONE NO.
FAX NO.
LAST OR MOST RECENT DATE OF DISCRIMINATION
Clear Form
Michigan Department
TITLE VI - COMPLAINT FORM
Page 1 of 2
of Transportation
0112 (12/19)
Title VI of the Civil Rights Act of 1964 states that, "No person in the United States shall on the basis of race, color, or
national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to discrimination
in any program, service, or activity receiving federal financial assistance."
This form may be used to file a complaint with the Michigan Department of Transportation (MOOT) for alleged
violations of Title VI of the Civil Rights Act of 1964.
If you need assistance completing this form,
please
contact us by phone at (517) 373-0980 or via FAX (517) 335-8841 or TDD/TTY through the Michigan Relay
Center at (800) 649-3777.
Only the complainant or the complainant's designated representative should complete this form.
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE
WORK TELEPHONE
FAX
lndividual(s) discriminated against, if different from above (use additional page(s) if necessary):
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE NO.
WORK TELEPHONE NO.
FAX NO.
PLEASE EXPLAIN YOUR RELATIONSHIP TO THE INDIVIDUAL(S) INDICATED ABOVE
Name of Agency and department or program that discriminated:
AGENCY AND DEPARTMENT NAME
NAME OF INDIVIDUAL (If known)
STREET ADDRESS
I I
CITY
STATE
ZIP CODE
I
TELEPHONE NO.
FAX NO.
LAST OR MOST RECENT DATE OF DISCRIMINATION
MOOT 0112 (12/19)
Page 2 of 2
Alleged discrimination:
Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to
know the act was discriminatory within the 180 day period, you have 60 days after you became aware to file your
complaint.
If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment
of you or others by the agency or department indicated above, please indicate below the basis on which you believe
these discriminatory actions were taken. (Check all that apply)
Example:
If you believe that you were discriminated against because you are African American, you
would mark the box labeled Race or Color and write African American in the space provided.
D
D
D
Race : _______
Color: _______
National origin:
-------
Explain:
Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the
alleged discrimination. (Attach additional sheets if necessary and provide a copy of written materials pertaining to
your case.)
SIGNATURE
DATE
Note: The laws enforced by this department prohibit retaliation or intimidation against anyone because that individual
has either taken action or participated in action to secure rights protected by these laws. If you experience retaliation
or intimidation separate from the discrimination alleged in this complaint or if you have questions regarding the
completion of this form, please contact:
MOOT Title VI Coordinator
Michigan Department of Transportation
425 W Ottawa Street
Lansing, Ml 48909
Phone: 517-241-7462
Fax: 517-335-0945
Email:
MDOT-TitleVl@michigan.gov
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